St. Albans Cooperative Creamery Inc. 138 Federal St. St. Albans, VT 05478 APPLICATION FOR EMPLOYMENT An Equal Opportunity Employer All applicants are considered without regard to race, color, gender, religion, national origin, age, marital or veteran status, mental or physical disability unrelated to job performance or any other legally protected status. POSITION APPLYING FOR: DATE: PERSONAL INFORMATION Legal name: First Last Middle Initial : Street City State Zip code Home Telephone: Other Telephone: E-mail: Social Security #: Driver s License #: State: (if position requires operation of a company vehicle) Are you legally eligible for employment in the United States? Yes No United States Visa status, if applicable: Are you at least 18 years old? Yes No Are you currently employed? Yes No Have you been employed with us before? Yes No If yes, dates employed: Have you filed an application with us before? Yes No Are you currently on lay-off status and subject to recall? Yes No May we contact your present employer? Yes No
Applicant : Page 2 POSITION INFORMATION Salary desired: $ Employment status desired: Full Time Part Time Temporary What hours are you available to work? If hired, when could you start? How did you hear about this job? EDUCATION Type of school and Location Attended Degree Received Subjects Studied Did you graduate? High School College / University Graduate School Tech School Other Special courses, training or experience acquired, including military experience: SKILLS Clerical / Office skills Computer skills of software: PC Mac WPM Languages Other special knowledge or skills Please describe any other experience, abilities or skills that might be helpful in considering your application:
Applicant : Page 3 EMPLOYMENT HISTORY Starting with current or most recent 1. EMPLOYER: Duties: 2. EMPLOYER: Duties: 3. EMPLOYER: Duties: 4. EMPLOYER: Duties:
Applicant : Page 4 REFERENCES MUST BE BUSINESS/EMPLOYMENT REFERENCES (not personal) 1. 2. 3. 4. CERTIFICATION & AUTHORIZATION I hereby certify that all statements made in this application are true and correct to the best of my knowledge and belief. I understand that any misrepresentations or omissions of facts in this application are grounds for disqualification from further consideration or for dismissal from employment. I authorize the company to inquire into my educational, professional and past employment history references as needed to research my qualifications for this position. If employed, I agree to conform to the rules, regulations and policies of the company. I understand that I will be an employee at will and either the company or I may terminate my employment relationship at any time for any reason not in violation of law. I hereby acknowledge that I have read and fully understand the forgoing and seek employment under these conditions. Signature of Applicant Date
Applicant : Page 5 Must Complete if Applying for CDL Position Driver's License Information: all licenses held within the last 3 years: Experience: Type of vehicle driven To Approximate mileage driven Type of vehicle driven To Approximate mileage driven Type of vehicle driven To Approximate mileage driven All Accidents within the last 3 years: (If none, write NONE) Date _ Describe Fatalities Injuries Date _ Describe Fatalities Injuries Date _ Describe Fatalities Injuries List all Traffic Violations Convictions with in the last 3 years: (If none, write NONE)
Applicant : Page 6 Must Complete if Applying for CDL Position Have you ever had any driver license denied, suspended, revoked or canceled by any issuing state agency? Yes No If yes; state of issuance; explanation: Were you subject to the Federal Motor Carrier Safety Regulations during the last 10 years? Yes No Were you subject to 49 CFR part 40 controlled substance and alcohol testing during the last 10 years? Yes No For driver applicants of commercial motor vehicles that require a Commercial Driver License (CDL) the applicant must disclose their controlled substance and alcohol status per the requirements of 49 CFR part 40.25(j). As a prospective driver employee, you have the right to review information provided by previous employers. You have the right to have errors in the information corrected by the previous employer(s) and for that previous employer(s) to re-send the corrected information to the prospective employer; the right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information. Driver employees who have previous Department of Transportation regulated employment history in the preceding three years, and wish to review previous employer p r o v i d e d i n v e s t i g a t i v e information, must submit a written request to the prospective employer, which may be done at any time, including when applying or as late as thirty (30) days after being employed or being no tified of denial of employment. The prospective employer must provide this information to the applicant within five (5) business days of receiving the written request. If the prospective employer has not yet received the requested information from the previous employer(s), then the five (5) business day deadlines will begin when the prospective e employer receives the requested safety performance history information. If the driver has not arranged to pick up or receive the requested records with in thirty (30) days of the prospective employer making them available, the prospective motor carrier may consider the driver to have waived their request to review the records. CERTIFICATION & AUTHORIZATION I hereby certify that all statements made in this application are true and correct to the best of my knowledge and belief. I understand that any misrepresentations or omissions of facts in this application are grounds for disqualification from further consideration or for dismissal from employment. Signature of Applicant Date